Vox carried an excellent Dylan Scott interview with Avik Roy this week. Roy is a health care policy expert for whom I have great respect. Among other health care issues, I have quoted him in the recent past on the faulty Congressional Budget Office (CBO) projections for Obamacare enrollment, which have consistently overshot actual enrollment. In this interview, Roy explains his current views on the health care insurance reform process and, in particular, the American Health Care Act (AHCA), the bill passed by the House of Representatives last month. The interview provides a good follow-up to my “musings” post on Sacred Cow Chips earlier this week.

Roy provides good explanations of some of the AHCA’s regulatory changes that have merit. These include:

relaxation of Obamacare’s community rating standards, meaning that insurers have more flexibility to charge premia based on age and other risk factors, thus mitigating the pricing distortions caused by cross-subsidies on the individual market;

a rollback in the required minimum actuarial value (AV) of an insurance plan (the ratio of plan-paid medical expenses to total medical expenses);

elimination of federal essential benefits requirements.

Roy provides context for these proposed changes relative to Obamacare. For example, regarding AV, he says:

“[In] the old individual market, prior to Obamacare, the typical actuarial value of a plan was about 40 percent. Obamacare drives that up effectively to 70 percent. That has a corresponding effect on premiums; it makes premiums a lot more expensive. In the AHCA, those actuarial value mandates are repealed. Which should provide a lot more opportunity for plans to design more affordable insurance policies for individuals.“

Even with Obamacare’s high AV requirements, an insurer could make money by virtue of the law’s “risk corridors”, which were intended to cover losses for insurers as they adjusted to the new regulations and as the exchange market matured, but those bailouts were temporary, and development of the exchanges did not go exactly as hoped. Insurers have been ending their participation in the exchange market, leaving even less than the limited choices available under Obamacare and little competition to restrain pricing.

On essential benefits, Roy reminds us that every state has essential benefit regulations of its own. These mandates create an unfortunate obstacle to interstate competition, as I discussed in March in “Benefit Mandates Bar Interstate Competition“. Nevertheless, the federal mandates have created additional complexities and added costs to cover risks that a) are not common to the risk pool, or b) cover benefits that are not risk-related and therefore inappropriate as insurance.

Roy also defends the AHCA’s protection of individuals with pre-existing conditions. One fact often overlooked is that burdening the individual market with coverage of pre-existing conditions made Obamacare less workable from the start, simultaneously driving up premiums and sending insurers for the hills. These risks can and should be handled separately, and the AHCA offers subsidies that should be up to the task:

“… if you look at Obamacare, the mechanisms in Obamacare’s exchanges that served as a way to fund coverage for sick people, they were spending $8 billion a year on that program. If you look at it that way, if $8 billion was enough under Obamacare, then maybe $15 billion a year is enough. I really don’t think that’s the problem with this bill.“

Roy contends that the big weakness in the AHCA is inadequate assistance to the poor in arranging affordable coverage. While highly critical of the CBO’s wild estimate of lost coverage (24 million), he does believe that the AHCA, as it stands, would involve a loss. He favors means-tested subsidies as a way of closing the gap, but acknowledges the incentive problems inherent in means testing. With time and a growing economy, and if the final legislation (and the purported stages 2 and 3 of reform) is successful in reducing the growth of health care costs relative to income, the subsidies would constitute a smaller drain on taxpayers.

As for Medicaid reform, Roy defends the AHCA’s approach:

“You start with the fact that access to care under Medicaid and health outcomes under Medicaid are very poor, far underperforming other health insurance programs and certainly way underperforming private insurance. Why does that problem exist? It exists because states have very little flexibility in how they managed their Medicaid costs. They’re basically not able to do anything to keep Medicaid costs under control, except pay doctors and hospitals less money for the same amount of care. As a result of that, people have poor access. By moving to a system in which you put Medicaid on a clear budget and you give states more flexibility in how they manage their Medicaid costs, you actually can end up with much better access to care and much better coverage.“

One point that deserves reemphasis is that a final plan, should one actually pass in both houses of Congress, will be different from the AHCA. From my perspective, the changes could be more aggressive in terms of deregulation on both the insurance side and in health care delivery. The health care sector has been overwhelmed by compliance costs and incentives for consolidation under Obamacar. Nobody bends cost curves downward by creating monopolies.

I’ve hardly done justice to the points made by Roy in this interview, but do read the whole thing!

Take a moment to consider some examples of the horrible misuse of words in political debates. David Harsanyi at Reason provides a few choice examples of the corrupted and misleading language used by Democrats:

the absence of a tax that “should” exist but doesn’t is a “loophole”;

failure to pay that tax is a “fraud”;

denial of “access” occurs when the state doesn’t give something to you for free;

“disenfranchisement” means you have to show an ID or wait in line;

“full rights” means the entire world must be a “safe space” for your actions or views, even if the rights of others are denied in the process.

These are all recent examples of mangled language from the two candidates for the Democrat Party nomination. But here’s a big one that Harsanyi overlooked: the misuse of the term “liberalism” to describe statism. In fact, he misuses the word “liberals” himself! In “Don’t Call Leftists Liberal; They’re Not!” on Sacred Cow Chips, I offered some thoughts on this bit of Newspeak practiced by so-called progressives. I can’t resist reposting the following quote of Daniel Klein quoting Kevin Williamson, which says it all (links are in the original post):

“Williamson [quotes] two leftist authors writing in The Nation, one decrying ‘unbridled individualism,’ the other ‘unfettered capitalism.’ Williamson concludes: ‘A ‘liberalism’ that is chiefly concerned with the many clever uses of bridles and fetters does not deserve the name. It never has.’”

The following quote from Harsanyi gives emphasis to the wrongful appropriation of “liberalism” by the left, though it relates more specifically to the misuse of the term “loophole”:

“Basically, all of life is a giant loophole until Democrats come up with a way to regulate or tax it. In its economic usage, “loophole” … creates the false impression that people are getting away with breaking the law. It’s a way to skip the entire debate portion of the conversation and get right to the accusation.“

Another behavioral characteristic of leftists is a certain self-righteous satisfaction that they hold the moral high ground on any number of issues. “The Smug Style in American Liberalism“by Emmitt Rensin in Vox takes a poke at this presumption. Of course, Rensin misuses “liberalism”. I find this review of the article by Kyle Smith an effective summary, and it’s even better because it skips what comes off as a long catalog of excuses by Rensin as to why leftists might be forgiven for patting themselves on the back. I give Rensin credit, however, for a good analysis of the origins of leftist “smug”, which he attributes to a backlash against defections from the Democrat coalition by working-class voters in the second half of the twentieth century. And I credit Rensin for his ultimate condemnation of undeserved leftist attitudes of superiority. Here are some difficult realities for the left cited by Rensin:

“Nothing is more confounding to the smug style than the fact that the average Republican is better educated and has a higher IQ than the average Democrat. That for every overpowered study finding superior liberal open-mindedness and intellect and knowledge, there is one to suggest that Republicans have the better of these qualities.“

Perhaps inventing new definitions for words in the service of rhetoric comes easy with pomposity. In the end, assertions that the left is more “caring”, “tolerant” or “peaceful” are balderdash. There are honest policy debates to be had about the best way to solve social problems and respect for the rights of others, but having experienced angry reactions in debate with befuddled leftists for myself, I wholly concur with this Kyle Smith observation:

Can the middle class be sold on federal pre-kindergarten dependency? Is pre-K always beneficial to children? All children? One of many issues agitating the “government-must-do-something” crowd is universal pre-kindergarten. It’s a favorite topic of the Socialist-Democrat Bernie Sanders and, more recently, it became a campaign promise from the Democrat-Socialist Hillary Clinton. It’s typical of the freebies these two presidential candidates are compelled to promise their base. While federal funding of universal pre-K is often billed as way to assist low-income working families, the subsidies proposed are not well-targeted: Clinton’s proposal calls for pre-K subsidies for middle-class families as well. A “Pre-School For All” proposal by President Obama in 2013 required $75 billion in funding. These kinds of broad-based transfer payments aren’t cheap.

In addition to the expense, it’s not clear that pre-K schooling is beneficial to all children. In Vox, Ezra Klein describes a recent study on the efficacy of a pre-K program in Tennessee (hat tip: John Crawford). The selection of children for the pre-K and control groups was randomized by virtue of a “lottery” for admission in regions experiencing excess demand. Here is Klein’s description of the results:

“At the end of pre-K, the results look pretty much as you would expect: Teachers rates [sic] the children who went through pre-K as ‘being better prepared for kindergarten work, as having better behaviors related to learning in the classroom and as having more positive peer relations.’

The problem is those results dissipate by the end of kindergarten — by then, the group that attended pre-K is no better off than the group that didn’t — and then begin to reverse by the end of first grade. By the end of second grade, the children who attended the pre-K program are scoring lower on both behavioral and academic measures than the children who didn’t.“

Klein cites two other “high-quality” studies (one by Head Start) that are consistent with the findings in Tennessee. He also notes some weaknesses of earlier studies suggesting that pre-K provides developmental benefits.

Some prominent advocates of pre-K insist that there are long-term benefits that the recent studies fail to capture. If so, it is hard to square that belief with such negative results after three years. I suspect that there are significant developmental rewards for children who spend their days with family members or even family friends, and I am skeptical that improved socialization can be gained from full-time attendance at a public facility. Perhaps some children benefit, but clearly not all.

None of this is to suggest that low-income parents would not benefit economically from additional subsidies for early education. To the extent that the parents are able to earn more income, the entire household will benefit and perhaps even society will benefit. But this is a social safety net issue at its base, not a broad-based social need. Ideally, one’s prospects for income should have a strong bearing on fertility decisions. Individual families should not expect others to bear the costs. And as for the safety net, let’s face it, great parts of it would be unnecessary in the absence of the negative work and family incentives inherent in many transfer programs. Neutralizing the costs of raising children compounds the bad incentives.

Like so many other statist misadventures, the populist appeal of universal pre-K is a desire for a freebie at the expense of others. The politicians Sanders, Clinton and Obama understand that, and they recognize it as another pillar of support for the great federal highway of cradle-to-grave serfdom.

In what sense is “equality” a rational objective? Can it ever be achieved without aggression? It’s certainly admirable for individuals to treat all others fairly and without bias against personal traits. A society composed of individuals possessing that kind of integrity is one in which “equal opportunity” exists in an intuitive sense. Such a society would yield market outcomes that are free from personal discrimination.

There are many social pitfalls when central authorities attempt to enforce this sort of equality. There will always be minor and even random cases of treatment that someone considers unfair. Any effort to adjudicate such incidents comes at a great resource cost. The potential for moral hazard in pursuing grievances is also strong, and the enforcement authority may well have biases of its own.

Stronger forms of equality are even more difficult to achieve in a free society. There are many barriers to “equality” that most people would regard as natural, like genetics and the integrity of the family. And like family, many other barriers to equality are cultural virtues, such as educational and occupational rewards based on merit. The institution of strong private property rights provides an effective system of incentives that fosters efficient resource allocation, promoting economic growth and human well-being, but it’s rewards will not be distributed equally.

Institutionalized tampering with any of these features for the sake of equality tends to legitimize envy as a cause of social action. And the intrusions require design and enforcement of a system of social “overrides” by a central authority possessing police power. Needless to say, this must involve elements of aggression and tyranny. These overrides introduce significant risks to individual freedom and the functioning of markets, and are likely to cause widespread destruction of welfare. In that sense, forced equality cannot be a rational objective.

“A libertarian is perfectly at peace with the universal phenomenon of human difference. He does not wish it away, he does not shake his fist at it, he does not pretend not to notice it. It affords him another opportunity to marvel at a miracle of the market: its ability to incorporate just about anyone into the division of labor. … Indeed the division of labor is based on human difference.“

Rockwell goes on to explain the law of comparative advantage, which allows more productive and less productive individuals to profit by specializing in areas for which each has the lowest opportunity cost. And when producers compete for rewards, as Rockwell notes, average consumers (and rich ones and poor ones) are the ultimate beneficiaries.

Outcomes such as the inequality of wealth and income are not only impossible to avoid, they are natural consequences of economic freedom. Several earlier posts on Sacred Cow Chips have dealt with this topic, and can be viewed from the Home page by typing “inequality” into the search box near the top. For his part, Rockwell discusses the “Wilt Chamberlain” problem, whereby private demand to witness great athletic prowess results in a shift towards an unequal distribution of income:

“… the pattern of wealth distribution is disturbed as soon as anyone engages in any exchange at all. Are we to cancel the results of all these exchanges and return everyone’s money to the original owners? Is Chamberlain to be deprived of the money people freely chose to gave [sic] him in exchange for the entertainment he provided?“

The fact that “equality” is seldom well-defined as an actual objective should be met with skepticism. Here’s more Rockwell:

“It is precisely this lack of clarity that makes the idea of equality so advantageous for the state. No one is entirely sure what the principle of equality commits him to. And keeping up with its ever-changing demands is more difficult still. … Equality is a concept that cannot and will not be kept restrained or nailed down.”

He takes a dismal view of “cultural inequality” and “equality of opportunity” as worthwhile causes for invoking the power of the state. For example, two families in different economic circumstances will generally confer different opportunities to their children. Dylan Matthews at Vox makes the same point in “Equality of Opportunity“, though Matthews’ analysis is weak in several respects. The point here is that there is only so much that can be done to correct for unequal family-related endowments without undermining the integrity of the family (not to mention property rights). This has long been a bone of contention with respect to the design of U.S. welfare programs. But the problem is much deeper:

“In the course of working toward equality, the state expands its power at the expense of other forms of human association, including the family itself. The family has always been the primary obstacle to the egalitarian program. The very fact that parents differ in their knowledge, skill levels, and devotion to their offspring means that children in no two households can ever be raised ‘equally.’

Robert Nisbet, the Columbia University sociologist, openly wondered if [John] Rawls would be honest enough to admit that his system, if followed to its logical conclusion, had to lead to the abolition of the family. ‘I have always found treatment of the family to be an excellent indicator of the degree of zeal and authoritarianism, overt or latent, in a moral philosopher or political theorist,’ Nisbet said.“

And here is Rawls himself expressing doubts, as quoted by Rockwell:

“It seems that when fair opportunity (as it has been defined) is satisfied, the family will lead to unequal chances between individuals. Is the family to be abolished then? Taken by itself and given a certain primacy, the idea of equal opportunity inclines in this direction.“

The quest for “equality” is a creeping force. It infects economic life in a way that makes widespread gains in welfare difficult to achieve, diminishes expectations and fosters social devolution. It also leads to demands for eliminating useful distinctions, which can only be erased though aggression by the state. This forces a convergence toward the least common denominator throughout the culture. I believe the following statement by Rockwell rings true:

“The obsession with equality… undermines every indicator of health we might look for in a civilization. It involves a madness so complete that although it flirts with the destruction of the family…. It leads to the destruction of standards — scholarly, cultural, and behavioral. It is based on assertion rather than evidence, and it attempts to gain ground not through rational argument but by intimidating opponents into silence. There is nothing honorable or admirable about any aspect of the egalitarian program.“

In the wake of the shooting of two TV journalists in Roanoke, VA this past week, a new spate of anti-gun memes has appeared. Some have used a collection of illustrations in Vox as a source, most of which suffer from conceptual problems discussed in this report by the Crime Prevention Research Center (CPRC): “Comparing Murder Rates and Gun Ownership Across Countries“. These issues are summarized below:

Homicides are not measured consistently across countries: For example, England counts only homicides for which there is a conviction, artificially deflating the number of homicides. In the U.S., homicides are counted even if there is no arrest. Counting only arrests would cut the reported U.S. murder rate by more than half. Counting only convictions would cut the rate still more.

A related issue is the number of defensive gun uses (DGUs — two posts that deal with DGUs and other topics related to gun violence appear at the link). DGUs are often non-fatal, but they undoubtedly increase the count of homicides in the U.S. That won’t hold in countries where official reporting of homicides differs. Here is John Stossel on the topic of DGUs:

“Often those guns are used to prevent crime. The homeowner pulls out the gun and the attacker flees. No one knows how often this happens because these prevented crimes don’t become news and don’t get reported to the government, but an estimate from the Violence Policy Center suggests crimes may be prevented by guns tens of thousands of times per year.”

Cross-country differences in gun homicides may not be reflected in total homicides because a percentage of the gun incidents would occur whether or not the perpetrator had access to a gun. Moreover, a number of countries with high total homicide rates do not report gun homicides.

“Mass shootings” can be defined in a variety of ways. Should they include acts of terrorism? Should they include only incidents involving a single shooter? Should they include gang shootouts? Should they include only incidents that occur “in public”? Should they include only incidents involving a death? Some implications of these definitional differences can be found here.

Comparing “civilian gun ownership” across countries can distort conclusions. Countries like Switzerland and Israel allow citizens to keep guns issued by the military in their homes, which reduces their official tallies. Both countries, like a number of others, have high rates of gun possession but very low firearm homicide rates.

The number of guns per capital is misleading because a relatively small number of individuals or households own multiple guns. Gun ownership rates are probably better for addressing the question of access to guns.

Comparing gun ownership across “civilized” countries introduces an arbitrary element, because there is no widely-accepted definition of “civilized”. Developed countries, as defined by the OECD, represents a better standard. Among developed countries, more gun ownership is associated with lower homicide rates.

Cross-sectional data may be confounded by endogenous influences. For example, high crime leads to more homicides and to more DGUs, which inflates homicides based on the U.S. definition. Or, high crime and homicides might lead local governments to impose strict gun control laws. But do those laws lead to even more homicides? Controlling for confounding influences is difficult, but it is possible to address causality based on responses to significant events, such as changes in gun control laws.

I maintain that gun control measures are more likely to give the appearance of effectiveness in the context of a history and culture of limited gun ownership. However, where gun ownership is historically extensive and deeply embedded in the culture, gun control measures may be counter-productive. Criminals can acquire guns on the black market, but bans prevent law-abiding citizens from using guns to defend themselves and undermine the prevention of gun violence.

Better to reform unproductive laws that criminalize harmless behavior, such as the drug trade and prostitution. Prohibitions create profit opportunities in underground activity and often lead to gangland violence. And it is better to reform laws and social policies that discourage or eliminate opportunities for legal work, such as many welfare programs and the minimum wage.

Fortunately, gun control is going nowhere politically. Gun ownership among the law abiding continues to grow, and most voters support Second Amendment rights, especially when security is tenuous. Smart Democrats know that gun control is a losing proposition for them, even if their left flank remains enamored with the idea. That’s a very good thing.

Here’s a post-debate follow-up on Donald Trump the Shape Shifter: I’m surprised to hear anyone praising his performance after that debacle. He came off as a dick, and that’s really The Donald. I thought so before I heard that he suggested Megyn Kelly was menstruating that evening. Megan was tough, but please…. Trump is a loud-mouthed, offensive, and often incoherent bully.

Two Trump moments that I thought were amazing were his exchange with Brett Baier about political donations and his dust-up with Rand Paul over a single-payer health care system.

On donations, Trump seemed to take satisfaction in the fact that Hillary Clinton “had no choice” but to attend his wedding after he gave to her Senate campaign. He then made the following statement, which made me laugh:

“I will tell you that our system is broken. I gave to many people. Before this, before two months ago, I was a businessman. I give to everybody. When they call, I give. And you know what? When I need something from them, two years later, three years later, I call them. They are there for me. And that’s a broken system.“

Should I love him or hate him for that statement? He admits with no shame that he participates in crony capitalism, and he realizes that it’s corrupt. Andrew Popkin at Vox has a good analysis:

“Something Trump identifies that doesn’t always get mentioned is the way transactional politics transcend partisanship and ideology. Trump gave to Democrats and he gave to Republicans. He didn’t care what they believed. He cared what they could do for him. He wasn’t supporting them — he was buying them, and that’s completely different.“

It’s convenient for Trump to brag that he doesn’t need donations from others when campaigning. When he’s on the other side of the table, he’s happy to participate in the corruption. Did Trump buy the politicians who helped him arrange eminent domain actions against property owners who were in the way of his developments? He’s also quite proud of his use of bankruptcy laws allowing him to stiff lenders and investors in his enterprises. By the way, in comparing his four corporate bankruptcies to the many “deals” he’s executed over the years, he’d have you believe that the “deal” is always the relevant unit for a bankruptcy proceeding. That’s loose and misleading jargon.

I have said that Trump’s supporters really don’t know what their getting. Perhaps he won’t tell anyone because he’d lose “leverage”. A prime example of Trump’s shiftiness was his response to the following question on single-payer health care systems, including his attempt to embarrass Rand Paul:

Baier: “Now, 15 years ago, you called yourself a liberal on health care. You were for a single-payer system, a Canadian-style system. Why were you for that then and why aren’t you for it now?“

As Peter Suderman noted, Trump’s response to this question about health care began with his views on the war in Iraq. Donald’s rules…. But eventually, he addressed the health care question with a stream of words that thinking people might have been tempted to process logically in order to divine a coherent “Trump” position on the issue, but that would have been a mistake:

“As far as single payer, it works in Canada. It works incredibly well in Scotland. It could have worked in a different age, which is the age you’re talking about here.

What I’d like to see is a private system without the artificial lines around every state. I have a big company with thousands and thousands of employees. And if I’m negotiating in New York or in New Jersey or in California, I have like one bidder. Nobody can bid. You know why? Because the insurance companies are making a fortune because they have control of the politicians, of course, with the exception of the politicians on this stage. But they have total control of the politicians. They’re making a fortune.“

This is not a great moment of clarity for Trump. We still don’t know what he has in mind. He demonstrates that he doesn’t quite understand the inherent flaws in single-payer. If his complaint is with consolidation of the health insurance industry, single-payer would imply an even greater consolidation, indeed, a monopoly. A “private system” does not rule out single-payer. While the insurance companies have undoubtedly influenced politicians, just as Trump has, why is he complaining about a lack of choice, having just asserted that single-payer could work so well? And artificial lines have to do with non-price rationing, a typical feature of government intervention in markets. Thus far, the profits of under-pricing insurers have been protected by so-called “risk corridors” built into Obamacare. Would Trump allow health care providers and insurers to reprice in order to eliminate “artificial lines”? Trump’s words did not settle any questions about his position.

The end of Trump’s response is this:

“And then we have to take care of the people that can’t take care of themselves. And I will do that through a different system.“

So… was Trump still talking about single-payer or not? I forgive Rand Paul for imagining that he was. It was the only solid statement that one could cling to in Trump’s ramble.

Here is Suderman’s summary of Trump’s response with an account of the exchange with Rand Paul that followed:

“What matters is that [Trump] would be different. Different how? So very, very different—and definitely not a moron/loser/dummy/incompetent (pick one) like this other guy.

This is how Trump responds to almost everything: By not answering the question, by babbling out some at-best semi-relevant references, by promising to somehow be different and better without explaining how or why, and then by lobbing an insult.

An insult is how Trump finishes the Obamacare exchange as well. After Trump finishes answering the question, Sen. Rand Paul cuts in, saying, ‘News flash, the Republican Party’s been fighting against a single-payer system for a decade. So I think you’re on the wrong side of this if you’re still arguing for a single-payer system.’ [SCC’s bolding]

The gist, as always, is that someone else—indeed, practically everyone else—is a dummy, a loser, a politician. Trump is the only one who really gets it, whatever it is.“

While I thought Rand Paul’s interjectory approach to debating was unwise, his comment to Trump was on-target, and he even qualified it. Trump responded with snark. Trump has yet to take a real position on health care in this campaign, but he has supported single-payer in the past. He doesn’t want to go to the trouble of deciding or revealing a specific plan just yet. Perhaps he’s “maintaining leverage”, keeping his options open, because he’s such a smart businessman. If you want to treat politics like a business deal, fine, but smart voters should be your partners, and they will expect you to reveal your terms.

The conduct of police has been called into question by events in Ferguson, Missouri, both in terms of prosecuting their day-to-day law enforcement duties and whether the “militarization” of local police is a healthy development. Glen Reynolds has some good suggestions for ensuring safer and more productive interactions between police and the public. He forgot to mention that we should end the war on drugs, but I’m sure he’d agree!

The conduct of police has been called into question by events in Ferguson, Missouri, both in terms of prosecuting their day-to-day law enforcement duties and whether the “militarization” of local police is a healthy development. Glen Reynolds has some good suggestions for ensuring safer and more productive interactions between police and the public. He forgot to mention that we should end the war on drugs, but I’m sure he’d agree!

Here are seven reasons birth control pills shouldn’t require a prescription, offered by Adrianna McIntyre in Vox. There is much concern over “access” to contraceptives in the wake of the Hobby Lobby decision. While any new concern is largely misplaced, the biggest impediments to access might well be the prescription status of these drugs and their cost. Making contraceptives available over-the-counter would do a great deal to reduce these problems while leaving everyone else with a clear conscience. In fact, it would greatly improve access for the uninsured, a group which will remain large despite the best intentions of Obamacare supporters. As the Vox article notes, physicians support the move to make contraceptives available OTC, and it is highly feasible politically, though support will be contingent on certain safeguards, such as restrictions on sales to minors. Otherwise, it is a classic “small government” solution.

In advanced civilizations the period loosely called Alexandrian is usually associated with flexible morals, perfunctory religion, populist standards and cosmopolitan tastes, feminism, exotic cults, and the rapid turnover of high and low fads---in short, a falling away (which is all that decadence means) from the strictness of traditional rules, embodied in character and inforced from within. -- Jacques Barzun